Provider Demographics
NPI:1518529197
Name:GRAY, DYLAN AMELIA (MSW, LGSW)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:AMELIA
Last Name:GRAY
Suffix:
Gender:F
Credentials:MSW, LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3528 23RD AVE S APT 1
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-3880
Mailing Address - Country:US
Mailing Address - Phone:774-526-1520
Mailing Address - Fax:
Practice Address - Street 1:2230 COMO AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-1720
Practice Address - Country:US
Practice Address - Phone:651-645-5323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN56077104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker